How are you?
It’s a well-worn greeting and one that most often elicits the reflexive response:
“I’m doing well.”
For that reason, notes Hopkins internist Mary Catherine Beach, doctors should not stop there when starting off a patient visit. The most effective follow-up?
“Is there anything in particular you want to discuss today?”
That’s among the key findings of a recent study Beach and her team conducted to pinpoint the most effective communication for conducting patient exams. It’s an increasingly important issue, given the time constraints facing today’s doctors and the growing volume of topics they must cover in a visit.
“When it comes to ‘agenda setting,’ we found that doctors should elicit patient agendas by using direct language and solicit additional concerns using ‘what else?’ vs. ‘anything else?’ because patients are more likely to raise concerns to direct questions,” notes Beach. Unfortunately, she says, her study found “the most effective agenda-soliciting questions are used least frequently by clinicians.” The result? Patients leave their visit without getting important concerns addressed.
Beach, who is co-director of CIM’s new Initiative for Humanizing Medicine and a Mary Gallo CIM Scholar, has been on a careerlong mission to improve the way clinicians communicate with patients. Her research, conducted in collaboration with dozens of researchers across Johns Hopkins, is probing issues such as: How can physicians best find out whether patients are taking their medications? What is the most effective way to achieve shared decision-making with patients? How should doctors demonstrate empathy?
“Not only is good communication the most important part of humanizing health care — it is one of the most important ways we can deliver high-quality clinical care,” says Beach, who holds a joint appointment with Johns Hopkins’ Berman Institute of Bioethics. “If we can’t communicate accurately and make sure we’ve conveyed information in a way that is understandable, our patients won’t be able to be healed because they won’t take their medication correctly or we will get their diagnosis wrong.”
‘Let’s Unpack That’
Much of Beach’s clinical work has focused on care for patients with HIV. Medication adherence is crucial for keeping the virus tamped down, but studies have shown that one-quarter to one-half of patients don’t take their antiretroviral medication consistently. Moreover, physicians often fail to detect the non-adherence, “which means lost opportunities for them to counsel their patients,” Beach says.
So what are the best questions to elicit truthful responses? In a study that involved analysis of dozens of audio recordings of physician encounters with non-adherent patients, she and her team found that one type of question clearly outperformed all others: negatively framed questions — that is, asking when (rather than if) doses had been missed (“When was the last time you missed a dose? Do you remember?”)
“The goal for doctors is not to make the patient feel worse by admitting they haven’t taken their medication or to put them on the defensive — but to open the conversation further,” says Beach. “With this and other ongoing studies, we’ve found that negatively framed questions do that best, allowing doctors to follow up with neutral questions, such as: ‘What happened then?’ Or, ‘Tell me more about that.’ Or, ‘Let’s unpack that.’”
Beach has shared these findings with colleagues in the HIV ambulatory care practice at Johns Hopkins whose communications were analyzed for the study — and at a national conference. “I’ve found that clinicians are excited to learn about findings they can put into practice,” she says.
Objectively Speaking
In the medication adherence studies and in the many other communication studies Beach has led or collaborated on, the science is rigorous and the analysis methods are complex, involving case control studies, surveys, and audio and statistical analysis.
In the past, says Beach, “we tended to think of this general idea of ‘bedside manner’ as a vague, subjective concept that was ‘nice’ but not definable. That it couldn’t be evaluated in any kind of objective way.”
In fact, she emphasizes, effective doctor/patient communication can be measured and analyzed, resulting in definitive conclusions and actionable results — information valuable to clinicians at every stage of their careers.
“Teaching effective communication can’t just happen with a single course during the first year of medical school,” Beach says. “We need to reinforce a culture where it’s a constant source of learning throughout medical school and residency training, and it should be revisited in continuing medical education.”
She continues, “It’s my life’s mission to conduct research to inform these efforts to forge more meaningful human connections — and better outcomes for patients.”
